HOARSENESS / CHRONIC COUGH
Hoarseness is an abnormality of the voice due to a change in vocal cord structure and/or vibration. Many of the causes of hoarseness also result in chronic cough. The first and foremost duty in the work-up of these conditions is to rule out any life-threatening diagnoses, such as cancer of the larynx or lung. A history of smoking greatly increases the likelihood of these diseases. They can be identified by a thorough examination of the head, neck, and chest, including fiberoptic laryngoscopy (a small telescope passed through the nose to visualize the voice box), and a chest x-ray. Any suspicious lesions should be biopsied after CT scan imaging. Other pulmonary causes to be ruled out include chronic bronchitis and emphysema. These conditions, like lung cancer, will require a pulmonary consult.
Although any suspicious lesion should be biopsied, several vocal cord masses are easily recognizable and not confused with cancer. Vocal cord nodules appear after continued vocal cord use or abuse, such as singing, screaming, or preaching. Generally, voice rest is required to improve hoarseness. Nodules may be excised with the laser, but they are likely to return if the voice is not rested. Vocal cord polyps usually result from continued irritation of the cords due to postnasal drip, reflux of stomach acid, or smoking. If they fail to resolve with inhaled steroids, they too should be biopsied.
While hoarseness is technically different from dysphonia, these conditions also should be ruled out. They are due to neurologic causes such as tremors and spasms, or sometimes due to psychological problems. Often a neurology consult or a speech pathology consult will be necessary. Paralysis of the vocal cords may be due to neurologic conditions as well, although thyroid disorders and post-surgical complications are more common causes. Various surgical procedures exist to improve the voice when vocal cord paralysis is present.
Although it is necessary to rule out life-threatening conditions, the vast majority of persons with hoarseness and/or chronic cough will not have cancer, benign tumors, dysphonias, vocal cord paralysis, or chronic pulmonary disease. Most of these persons will have one or more of the following four conditions: postnasal drip from allergies or sinusitis, reflux of stomach acid, chronic irritation from cigarette smoke or other pollutants or asthma. Generally, the vocal cords will be swollen and red, but will have no masses and will move normally. The cough is usually intermittent and dry. There may be occasional wheezing.
A history of nasal symptoms will usually be present in allergies and sinusitis and postnasal drip can be seen on the exam. Treatment of the nasal condition with steroid sprays, antihistamines, decongestants, and possibly antibiotics will usually improve laryngitis and bronchitis as well.
A history of indigestion and heartburn will usually be present in the reflux of stomach acid. Complex tests can prove this condition but are generally not necessary. Treatment with anti-reflux and antacid medications will usually improve the symptoms.
Mild asthma is a common unrecognized cause of cough with or without wheezing. This can be diagnosed by pulmonary function testing called spirometry. Medical therapy includes bronchodilators and inhaled steroids. Severe asthma requires a pulmonary consult.
Finally, in rare cases where the diagnosis of hoarseness and chronic cough are elusive, a thorough check of the person’s medication record is necessary, as some medicines may cause a chronic cough. Inhaled steroids may improve hoarseness in cases of chronic laryngitis. Cough suppressants such as Robitussin DM and codeine may tame the chronic cough. None of these medicines, however, are superior to treating the underlying cause of these symptoms.